Ch. 23 – Pain Management during Labor

What are some factors in the patient’s pain relief decision process?
patient preference, past experiences, fear of complications, cultural influences, amount of sleep, childbirth education
What are some positives of having a medication-free birth (not taking any meds during labor)?
Patient with medication free birth report quicker recovery time, able to ambulate, eat, urinate, shower immediately following birth; newborn is more awake and alert, better able to bond and breastfeed and be orient to its surroundings.
What is the nurses role in pain relief during labor?
– Support decision for pharmaceutical pain relief
– Offer alternative therapies if pharmaceuticals not desired
– Support changes in decision
– Educate about options and intervene when needed
– Reassure that accepting medication for pain is not failure; If a woman is not coping with labor well, she will need pharmacologic intervention; there is the possibility of becoming so stressed and anxious that the woman hyperventilates and fights her labor; this leads to decreased oxygen to the fetus and a prolonged labor.
Before receiving any medication, what should the woman know or be taught about pain relief medication during labor?
– Type of medication administered
– Any medication allergies? Any family history of adverse reactions to the above?
– What the medication is intended to do
– Route of administration
– Implications for fetus/newborn
– Safety measures needed (for example, remain in bed – with side rails up)
– Side effects/complications
What are some examples of common Narcotics used during labor?
Demerol, morphine, Stadol, Fentanyl, Nubain
What are some examples of common Sedatives used during labor?
Ambien, valium, phenergan, Benadryl
Will narcotics take away the contraction pain during labor?
Narcotics cannot take the contraction pain away, but will allow the woman to rest in between contractions and cope with labor pain better
Can you ambulate after narcotic administration?
Nope
Which kinds of pain relief medications cross the placenta and which kinds do not?
Narcotics and sedatives cross the placental barrier; an epidural does not
What are some common side effects of pain relief medication during labor?
Narcotics – dizziness, drowsiness, prolonged labor, decreased effectiveness at end of labor; transfer to fetus; need for Narcan
Epidural – hypotension, headache.
What is Systemic Analgesia?
aka –> IM/IV Narcotics!

Systemic analgesia is pain medication given IV or IM that does not result in complete loss of sensation or a reduction of motor functioning. While systemic analgesics does lessen the pain sensations, they typically do not eliminate pain completely

What are some Maternal Criteria that must be checked in order for systemic analgesia (narcotics) to be administered?
– Woman is willing to receive medication after being advised about it; or she requests it!
– Vitals are stable; know allergies too!
– Have an established labor pattern
– Contraindications (such as drug allergies, respiratory compromise, or current drug dependence) are not present
– Knowledge of other medications being administered, such as magnesium sulfate or tocolytics
– Also normal contraction patterns, dilatation, effacement, fetal presenting part, and station
What are some Fetal Criteria that must be checked in order for systemic analgesia (narcotics) to be administered to the mother?
– FHR is normal, between 110-160
– Reactive non-stress test (NST) (accelerations of FHR are present with fetal movement)
– Variability is present
– Periodic late decelerations or non-periodic decelerations are absent
Why are sedatives given during labor and when should they be used and not be used?
– sedatives promote relaxation and allow woman to sleep for a few hours
– don’t give to woman in active labor (cause resp. depression in infant)
– don’t help with pain, can actually increase reaction to painful stimuli so only give sedatives to decrease anxiety and promote sleep
– sedatives include barbiturates, benzodiazepines, and H1-receptor antagonists
– MUST keep track of mom’s repiratory rate! Could sedate too much (spo2 sat on them to watch)
Which medications can potentiate the effects of narcotics and help them last a little longer?
Phenergan and Benadryl both potentiate the effects of narcotics and help last a little longer
What can be given to reverse mild respiratory depression, sedation, and hypotension followed by opioid use?
naloxone (Narcan) which is an opiate antagonist
What can happen when Narcan is given to a woman or a newborn who is physically dependent on narcotics (such as stadol, nubain, demerol)?
withdrawal s/s!
Why is it important to establish a labor pattern before administering pain medication to a woman in labor?
When mom requests pain med, you can do VE to check status. If in early labor and takes narcotics, it can actually slow or stop labor. So have to establish a labor pattern!
When administering pain medication to a women in labor which routes do you administer?
Usually IV first and then IM because IV is instant and IM will work when IV starts slowing down
What is Regional Anesthesia?
Regional anesthesia is the temporary and reversible loss of sensation produced by injecting an anesthetic agent (called a local anesthetic) into an area that will bring the agent into direct contact with nervous tissue. Loss of sensation occurs; regional anesthesia deemed safer than general anesthesia
(Ex. Epidural and spinal)
What is an epidural? (overview)
A type of regional anesthesia used during labor and vaginal birth as well as cesarean birth; given in first and second stage of labor; involves injection of local anesthetic agent into epidural space (between dura matter and ligamentum flavum); most often used as a continuous block to provide analgesia and anesthesia from active labor until birth and episiotomy repair; complete pain relief is achieved in 85% of women; preferred method of pain relief for laboring women
What is a spinal? (overview)
A type of regional anesthesia which provides immediate onset of anesthesia; in a spinal block, a local anesthetic is injected directly into the spinal fluid in the subarachnoid space to provide analgesia for Cesarean birth. Unlike epidural, spinal allows anesthesia to mix directly with CSF, which eliminates “windows” where coverage is not obtained
What is a combined spinal/epidural?
with this approach, spinal analgesia may be given in latent phase for pain relief while epidural is given when active labor begins
What are some advantages of an epidural?
epidural provides good analgesia that alters maternal physiologic response to pain, the woman is fully awake during labor and birth, allows different blocking for each stage of labor, dose can be adjusted
What are some advantages of a spinal block?
immediate onset of anesthesia, ease of administration, smaller drug volume, regional block of choice in acute OB emergencies since its safest and fastest anesthesia technique
What are some disadvantages of an epidural?
maternal hypotension, onset of analgesia may not occur for up to 30 minutes, costly
What are some disadvantages of a spinal block?
high incidence of hypotension which leads to greater potential for fetal hypoxia; intrauterine manipulation is more difficult (because uterine tone is maintained), its short acting and hard to maintain for long periods of time
What are nursing care and interventions done PRIOR to placement of an epidural or spinal block (regional anesthesia)?
Prior to placement:

– make sure NO low platelets –> at least 100,000
– no surgery on back that would get in way of epidural/spinal
– Need to preload rapid infusion of IV fluid (1-2 bags or Liters); this offsets the sympathetic blockade that sometimes occurs and drops BP (hypotension)
– Will usually administer test dose first to make sure no response; and they make sure they are not in a blood vessel. Then they connect it to infusion pump or keep the catheter in to do a bolus every now and then

What are nursing care and interventions done DURING placement of an epidural or spinal block (regional anesthesia)?
– position the woman, and have her focus on you and don’t move during; She may be sitting or laying on side depending on what physician orders
– Sitting position: with shoulders rolled forward (arched cat back!) and back exposed for needle insertion
– feet hanging over bed
– knees out wide so belly hangs between legs
What are nursing care and interventions done FOLLOWING placement of an epidural or spinal block (regional anesthesia)?
Following placement:

– she is laid flat with a tilt (monitor bp) and check for pain relief (usually takes 15 minutes to start working; woman may feel warmth moving up body)
check to see if the contractions are getting better and better
– fetus may get tachy, brady, or late decels and mom may get nauseated and diaphoretic –> this means blood is not going to the baby due to major diversion and large vasodilation of blood to major organs
– If the above occurs –> So you can IV fluids bolus, turn the woman to her side, change her position flatter (not sitting up) so that blood can stay at even level, can give ephedrine by calling Dr and letting them know situation (ephedrine is very potent vasoconstrictor; goes in and shrinks vessels and doesn’t affect placental vessels)
– Once she is nice and numb, put in Foley to keep bladder empty esp. since she cant feel down there

What is the proper position of needle insertion and technique for epidural block?
Needle goes in ligamentum flavum, tip of needle then into epidural space, and force of injection pushing dura away from needle tip
What are some extra techniques used for administration of a spinal block?
Spinal anesthesia is usually used only for C-section. Small amount of meds (2ml) and goes to spinal fluid and works very rapidly. Once laid down, she has towel rolled under hips. She recieves a preload prior to spinal anesthesia. After administration of anesthesia she is monitored for hypotension
What is a common side effect of spinal block that may be reported (besides hypotension)?
Spinal Headache!

This happens when spinal fluid leaks out (this can happen in an epidural as well). So make sure you monitor for this as well as hypotension. Lay them as flat as possible after and can ask them to drink caffeine if they have a HA.

When administering an epidural block, the woman may positioned on her right or left side or she may be in a sitting position leaned over. What is the proper positioning technique if the woman is laying on the bed to receive an epidural block?
Lay woman at the edge of the bed (the mattress is firmer and provides more support). The back is straight and vertical, the shoulders are square and upper shoulder has not fallen forward, and the legs will be slightly flexed usually with a pillow between them (the upper leg is prevented from rolling forward). Use pillows so that the shoulders dont fall forward and so that the head wont be too low
What is a pudendal block and when is it used?
– Pudendal block provides perineal anesthesia for the second stage of labor, birth, and episiotomy repair.
– Provides relief of pain from perineal distention but does not relieve pain from uterine contraction
– Used for woman who used only narcotics or natural and is now in pushing part of labor and is starting to have pain. 10ml of Lidocaine, long needle is put in pudendal nerve on both sides of vagina. Only blocks pain in vaginal area
What are some advantages of pudendal block?
Easy to administer and absence of maternal hypotension are advantages
What are some disadvantages of pudendal block?
– Urge to bear down may be decreased
– Complications
What are some complications which may be seen with administration of a pudendal block?
Complications:

– Systemic toxic reaction
– Broad ligament hematoma
– Perforation of the rectum
– Trauma to the sciatic nerve

What is general anesthesia and when is it used?
Induced unconsciousness; use in OB setting declining but still used for cesarean birth and surgical intervention with some OB complications

– usually in emergency situations!

What nursing management and interventions are done PRIOR to administration of general anesthesia for labor?
– Prophylactic antacid therapy
– Before administration, woman should have wedge under her hip to displace the uterus and avoid vena caval compression in the supine position
– Pre-oxygenate woman with 3 to 5 minutes of 100% oxygen
– IV fluids started so that access to intravascular space is immediately available
What does the nurse need to do during the process of rapid induction of general anesthesia?
The nurse applies cricoid pressure!

– Depressing the cricoid cartilage 2 to 3 cm posteriorly so that the esophagus is occluded. Pressure is continued until anesthesiologist has placed the cuffed endotracheal tube and indicates that pressure can be released

– Woman’s neck should be supported with other hand during cricoid pressure application